Acne Keloidalis Nuchae (AKN), also known as acne keloidalis, or folliculitis keloidalis, is a type of folliculitis (inflammation of the follicle) that can lead to scarring bumps and permanent alopecia. AKN primarily affects the posterior neck in men but can also occur in women. AKN occurs most commonly in African Americans and less commonly amongst Hispanics, Asians, and Caucasians.
AKN initially presents as itchy inflamed bumps (folliculitis) and pustules along the posterior lower hairline, or back of the scalp. These bumps can turn into firm keloid scars which will destroy the hair follicle. With a chronic course, the bumps can turn into thick keloid-like plaques with surrounding crust, drainage, and discomfort.
The cause for AKN is still being investigated; however there is evidence that it is an inflammatory condition similar to acne. The lesions can start by trauma in the area. We are not sure if the trauma is a cut from a clipper, an ingrown hair, pulling hair too tight, or heat. Previous thoughts were the hairs were cut far below the skin surface and those curly hairs grew into the skin causing irritation that formed an ingrown hair bump. There was also the thought that barbers were not cleaning their equipment properly and introducing bacteria and other organisms into the scalp with the use of clippers. However, this condition can occur in women who do not shave their scalps or neck, and in individuals with straight hairs.
To tackle to the concept of dirty clippers, if this were an issue of contaminated clippers, then a pattern would be seen that all the individuals on that day would have been “infected” with the same clippers. In other words, if bacteria were on those clippers prior to cutting client #1″affected person”, then the bacteria were on the clippers for client #2, client #3, and so on. So everyone who had their hair cut that day would return with the same reaction on the scalp. Typically barbers will see a client with this condition but had they previously cut the client’s scalp then everyone coming back in would have the same complaint. This is not the case.
Early detection is important to prevent progression of the condition and salvage hairs. Treatment is aimed at reducing the amount of inflammation so the bumps smooth down and the hairs regrow. If the inflammation is longstanding, hair regrowth may not be possible. Treatments include intralesional steroid injections, oral anti inflammatory medications, and topical steroid creams and solutions which can help with reducing the appearance and the symptoms of the affected area. Mild cases can be treated with topical benzoyl peroxide wash and acne medications. More advanced cases may still require systemic treatment in conjunction with surgical excision of areas. It is important to know when surgery is performed, hair cannot regrow into that area due to scar tissue. Additionally, new lesions may occur if the inflammatory process continues after surgery.
While close shaves are not a direct cause for the condition, I recommend patients to avoid irritation to the area during the acute treatment course (1-3 weeks). After that I advise patients to make sure they do not feel discomfort or too much heat when getting their hair cut. If hair is not desired in the affected area, laser hair removal is an option to help with reducing triggers of inflammation. Close monitoring and follow up is warranted to shut down any inflammation to halt the progression of the condition.
Dissecting cellulitis (DC) also known as Perifolliculitis Capitis Abscedens et Suffodiens is an inflammatory scalp condition that can lead to scarring alopecia. DC primarily affects males that are between the ages of20 to 40 years old and most commonly African Americans followed by Hispanics, then Caucasians. DC typically begans as a painful inflamed follicle (Acne-like bumps) involving the crown of the scalp or posterior neck that progresses into multiple boils. These boils can connect under the skin to form sinus tracts or canals which drain pus and/or blood.
At full development, the scalp will feel soft and boggy and pressing on one lesion may express pus at a distant lesion. The pressure of the fluid under the skin can crush overlying hair follicles destroying them and causing permanent hair loss. In studies, cultures were taken from numerous patients and found that the cause of DC was not due to a bacterial infection. However, because DC can lead to open sinus tracts and breaks in the skin the area is susceptible to develop a bacterial infection.
DC is diagnosed by exam and sometimes requires a scalp biopsy. When assessing for dissecting cellulitis, other systemic conditions must be ruled out that act similarly such as acne conglobata (bad cystic acne) or hidradenitis suppurativa (recurrent inflammatory boils). These conditions can all simultaneously occur due to hair follicles becoming blocked and causing an overactive inflammatory response . In addition, other scarring hair loss diagnoses must be rued out, such as pseudopelade of Brocq, tinea capitis (scalp fungus or ringworm), or folliculitis decalvans (future article coming).
Medical treatment is aimed at stopping the inflammatory process. Interestingly, the condition requires follicles to continue. Oral antibiotics can be used to treat secondary infections but are also used for their anti-inflammatory effects. Steroid injections work similarly to reduce inflammation locally when injected into the scalp. Combination regimens can be administered for severe cases. When treated with laser hair removal or surgery the lesions improve if not completely resolve. I emphasize the importance of healing chronic open wounds because they can increase the risk of developing a skin cancer in the affected area.
DC is a condition of blocked follicles which lead to increased inflammatory response. There is no evidence that it was started by dirty clippers or a bad hair cut. While I tell patients they can still get their hair cut, I emphasize that caution should be taken to reduce the amount of trauma and irritation to the scalp. Without treatment DC can wax and wane over a course of months to years and can cause the patient significant pain and psychological distress. Early treatment can prevent progression and more importantly prevent permanent alopecia and the formation of scar tissue over the scalp.
Pseudopelade of Brocq (PPB) is a hair loss condition with great debate behind the activity of the condition. There is thought that PPB is an actively smoldering primary inflammatory condition that can be slowed or stopped. Another belief is that PPB is the end result of any inflammatory alopecia and no further treatment is needed. The mechanism is unknown as to why this occurs. There are speculations about the cause of PPB including Borrelia infection, auto-immune origins, or genetics with or without environmental influences.
PPB primarily affects middle aged and older women although all ages including men and children can be affected as well. Many patients are not aware of the condition and it usually starts without symptoms and progresses slowly. Patients may notice smooth or dimpled patches of alopecia at the crown or sides of the scalp. These patches can contain single hairs, are usually skin colored, without scale or itching, and can track around the scalp like “footprints in the snow.”
PPB is diagnosed through scalp examination and biopsy. A biopsy is warranted to rule out other causes of inflammatory alopecia which can mimic PPB such as alopecia areata, discoid lupus, or lichen planopilaris. PPB is considered an inflammatory disorder although inflammation may or may not be visualized on the biopsy. When that biopsy is examined the follicles in PPB appear to be atrophic with shorter and finer hairs.
Treatment includes finding and treating any underlying inflammatory conditions. Topical steroid liquids and creams, scalp injections, oral anti-inflammatory medications can slow or stop the progression of PPB. PPB is self-limited and can start and stop without the patient knowing or without treatment. The endpoint can leave a few patches of alopecia to almost total scalp baldness. With any alopecia that can start again without symptoms, close follow up is necessary to monitor for flares. Early detection and treatment can prevent progression of hair loss and possibly reverse alopecia if caught early.
Lichen planopilaris (LPP) is an inflammatory scalp condition that leads to patchy scarring hair loss . LPP overlaps with other syndromes and conditions such as the previously-discussed Frontal fibrosing alopecia (FFA article) and Graham Little syndrome which is characterized by progressive scarring hair loss on the scalp, non-scarring hair loss in the underarm and groin, and spiky bumps located over hair follicles. LPP can also overlap with lichen planus, a similar inflammatory process that affects the skin on the body and develops purplish, flat, itchy bumps called lichen planus.
LPP affects woman more often than men. The FFA type affects primarily postmenopausal women while the Graham Little Syndrome affects primarily Caucasian women between ages 30-60 years1. There are studies looking at the correlation between LPP and thyroid disorders but further information is needed to make a definite link between the two conditions2.
The early stage of LPP typically presents as scaling or red bumps around each follicle on the frontal and crown of the scalp. Other symptoms experienced include tenderness, burning, and itching. As the condition progresses the inflammatory process starts destroying follicles, leaving behind scarred, white, patches of hair loss. Initially these patches may be small and diffuse but can spread wider and become connected with more severe disease.
Diagnosis is through an examination and sometimes biopsy. The scalp is assessed for scaling and redness around the follicels, the hairs are pulled to see if they remove easily. Trichoscopy (trichology) is used to assess if the follicles are present and to assess the root of the hair to determine which phase the hair is in (life cycle of hair). A full body exam is also performed to assess for lichen planus lesions on the skin, in the mouth, genitals, or nails. A biopsy can be helpful to assess for deeper inflammation of the scalp and show if activity is present or absent.
Treatment aims at reducing the inflammatory process. Topical steroids and non-steroidal agents are used at home. In-office steroid injections can help calm down inflammation at the site without the side effects of taking an oral steroid and can penetrate deeper than topical steroids. Oral medications are usually initiated for more advanced disease to help reduce inflammation. Close follow up is warranted to assess for symptoms and monitor for slowing and halting the progression of the condition.
- LászlóFG. Graham-Little-Piccardi-Lasseur syndrome: case report and review of the syndrome in men. Int J Dermatol. 2014;53(8):1019.
- Atanaskova Mesinkovska N, Brankov N, Piliang M et al. Association of lichen planopilaris with thyroid disease: a retrospective case-control study. Kyei A, Bergfeld WF. J Am Acad Dermatol. 2014;70(5):889.